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Huerta S, Raj R, Chang J. Botulinum Toxin A as an Adjunct for the Repair Giant Inguinal Hernias: Case Reports and a Review of the Literature. J Clin Med 2024; 13:1879. [PMID: 38610644 PMCID: PMC11012701 DOI: 10.3390/jcm13071879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/17/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
The management of giant inguinoscrotal hernias remains a challenge as a result of the loss of the intra-abdominal domain from long-standing hernia contents within the scrotum. Multiple techniques have been described for abdominal wall relaxation and augmentation to allow the safe return of viscera from the scrotum to the intraperitoneal cavity without adversely affecting cardiorespiratory physiology. Preoperative progressive pneumoperitoneum, phrenectomy, and component separation are but a few common techniques previously described as adjuncts to the management of these massively large hernias. However, these strategies require an additional invasive stage, and reproducibility remains challenging. Botulinum toxin A (BTA) has been successfully used for the management of complex ventral hernias. Its use for these hernias has shown reproducibility and a low side effect profile. In the present report, we describe our institutional experience with BTA for giant inguinal hernias in two patients and present a review of the literature. In one case, a 77-year-old man with a substantial cardiac history presented with a giant left inguinal hernia that was interfering with his activities of daily living. He had BTA six weeks prior to inguinal hernia repair. Repair was performed via an inguinal incision with a favorable return of the viscera into the peritoneum. He was discharged on the same day of the operation. A second patient, 78 years of age, had a giant right inguinoscrotal hernia. He had a significant cardiac history and was treated with BTA six weeks prior to inguinal hernia repair via a groin incision. Neither patient had complaints nor recurrence at 7- and 3-month follow-ups. While the literature on this topic is scarce, we found 13 cases of inguinal hernias treated with BTA as an adjunct. BTA might be a promising adjunct for the management of giant inguinoscrotal hernias in addition to or in place of current strategies.
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Affiliation(s)
- Sergio Huerta
- Department of Surgery, VA North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA;
| | - Roma Raj
- Department of Surgery, VA North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA;
| | - Jonathan Chang
- Department of Anesthesia and Pain Management, VA North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA;
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Huerta S. The best strategy for the management of inguinodynia is prevention. Hernia 2023; 27:1619-1620. [PMID: 36973466 DOI: 10.1007/s10029-023-02778-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 03/12/2023] [Indexed: 03/29/2023]
Affiliation(s)
- S Huerta
- Department of Surgery, VA North Texas Health Care System, University of Texas Southwestern Medical Center, 4500 S. Lancaster Road (112), Dallas, Texas, 75216, USA.
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3
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Rios-Diaz AJ, Cunning JR, Talwar AA, Christopher A, Broach RB, Hsu JY, Morris JB, Fischer JP. Reoperation Through a Prosthetic-Reinforced Abdominal Wall and Its Association With Postoperative Outcomes and Longitudinal Health Care Utilization. JAMA Surg 2022; 157:908-916. [PMID: 35921101 PMCID: PMC9350843 DOI: 10.1001/jamasurg.2022.3320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Prosthetic reinforcement of critically sized incisional hernias is necessary to decrease hernia recurrence, but long-term prosthetic-mesh footprint may increase complication risk during subsequent abdominal operations. Objective To investigate the association of prior incisional hernia repair with mesh (IHRWM) with postoperative outcomes and health care utilization after common abdominal operations. Design, Setting, and Participants This was a population-based, retrospective cohort study of patients undergoing inpatient abdominal surgical procedures during the period of January 2009 to December 2016, with at least 1 year of follow-up within 5 geographically diverse statewide inpatient/ambulatory databases (Florida, Iowa, Nebraska, New York, Utah). History of an abdominal operation was ascertained within the 3-year period preceding the index operation. Patients admitted to the hospital with a history of an abdominal operation (ie, bariatric, cholecystectomy, small- or large-bowel resection, prostatectomy, gynecologic) were identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification procedure codes. Patients with prior IHRWM were propensity score matched (1:1) to controls both with and without a history of an abdominal surgical procedure based on clinical and operative characteristics. Data analysis was conducted from March 1 to November 27, 2021. Main Outcomes and Measures The primary outcome was a composite of adverse postoperative outcomes (surgical and nonsurgical). Secondary outcomes included health care utilization determined by length of hospital stay, hospital charges, and 1-year readmissions. Logistic and Cox regression determined the association of prior IHRWM with the outcomes of interest. Additional subanalyses matched and compared patients with prior IHR without mesh (IHRWOM) to those with a history of an abdominal operation. Results Of the 914 105 patients undergoing common abdominal surgical procedures (81 123 bariatric [8.9%], 284 450 small- or large-bowel resection [31.1%], 223 768 cholecystectomy [24.5%], 33 183 prostatectomy [3.6%], and 291 581 gynecologic [31.9%]), all 3517 patients (age group: 46-55 years, 1547 [44.0%]; 2396 majority sex [68.1%]) with prior IHRWM were matched to patients without a history of abdominal surgical procedures. After matching, prior IHRWM was associated with increased overall complications (odds ratio [OR], 1.43; 95% CI, 1.27-1.60), surgical complications (OR, 1.51; 95% CI, 1.34-1.70), length of hospital stay (mean increase of 1.03 days; 95% CI, 0.56-1.49 days; P < .001), index admission charges (predicted mean difference of $11 896.10; 95% CI, $6096.80-$17 695.40; P < .001), and 1-year unplanned readmissions (hazard ratio, 1.14; 95% CI, 1.05-1.25; P = .002). This trend persisted even when comparing matched patients with prior IHRWM to patients with a history of abdominal surgical procedures, and the treatment outcome disappeared when comparing patients with prior IHRWOM to those without a previous abdominal operation. Conclusions and Relevance Reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk appeared to be independent of a history of abdominal surgical procedures and was magnified by the presence of a prosthetic-mesh footprint in the abdominal wall.
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Affiliation(s)
- Arturo J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jessica R Cunning
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Ankoor A Talwar
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Adrienne Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Jesse Y Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
| | - Jon B Morris
- Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
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Predictors of long-term mortality in octogenarian veterans following inguinal hernia repair. Hernia 2021; 26:243-249. [PMID: 34686941 DOI: 10.1007/s10029-021-02525-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND While elective inguinal hernia repair (IHR) in octogenarians carries a low 30-day mortality rate, long-term outcomes are uncharted. If on average, veteran octogenarians are expected to succumb to pre-existing cardiopulmonary disease within a year of diagnosis, watchful waiting might be advisable. This study interrogated long-term mortality and its predictors following elective IHR in veteran octogenarians. MATERIALS AND METHODS This is a retrospective analysis of 109 veterans (≥ 80 years of age), ten of which were nonagenarians who had an elective IHR. Data were dichotomized between deceased vs. non-deceased patients for univariable and multivariable analyses. Patient characteristics were also assessed in patients undergoing general (GA) vs. local (LA) anesthesia and corrected for unilateral repair and age. Kaplan-Meier curves were generated in corrected and uncorrected cohorts receiving GA vs. LA. RESULTS At the time of analysis, 46 (45.0%) octogenarians were deceased. The average time to death following IHR was 3.7 ± 2.9 years [range (37 days-12.4 years)]. Univariable analysis showed renal disease (19.9% vs. 5.3%), operative time (67.9 ± 29.0 vs. 56.1 ± 14.4 min) and use of GA (73.0% vs. 34.8%) associated with long-term mortality (all p < 0.01). Renal disease [odds ratio (95% confidence intervals) 4.1 (1.2-13.8)] and use of GA [5.0 (2.0-10.0)] were independent predictors of mortality. Patients undergoing LA (n = 62) were older, were more likely to have cardiac disease, and had a higher ASA compared to patients receiving GA (n = 47). After correcting for age, cardiac disease and higher ASA remained more common in patients submitting to LA. Long-term mortality was significantly higher in both matched and unmatched octogenarians undergoing GA. CONCLUSION Octogenarian veterans with a high burden of comorbid conditions are unlikely to experience short-term mortality because of their pre-existing conditions. Inguinal hernia repair should be offered to octogenarian veterans, but GA should be avoided whenever possible.
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Outcomes of obese compared to non-obese veterans undergoing open inguinal hernia repair: a case-control study. Hernia 2021; 25:1289-1294. [PMID: 33689047 DOI: 10.1007/s10029-021-02382-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 02/23/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal approach for inguinal hernia repair in the obese remains elusive. Minimally invasive techniques show equivocal results compared to the open method. None of the current analyses include a non-obese control group because the differences in factors leading to complications vary widely between these two cohorts. MATERIALS AND METHODS In the present study, we matched (1:1) obese to non-obese patients undergoing an open inguinal hernia repair. Matching was performed by age, hernia type (bilateral, inguinal, femoral, recurrent, primary, direct, pantaloon, and scrotal component), type of repair (tissue repair vs. mesh), concurrent umbilical hernia repair, current smoking, ASA Class, a history of DM and COPD. RESULTS Demographics in the unmatched cohorts demonstrated significantly (p < 0.05) wide differences between obese (n = 319) and non-obese (n = 1137) veterans: age (58.0- vs. 63.4-year-old), indirect hernia (37.7% vs. 45.5%), scrotal component (14.4% vs. 9.9%), current smoking (23.5% vs. 34.4%), DM (20.8% vs. 13.1%), OSA (13.2% vs. 3.6%), COPD (12.2% vs. 18.5%), and BPH (16.9% vs. 23.3). After matching, there were 300 obese and 300 non-obese patients available for analysis. There was no difference in 30-day morbidity between obese and non-obese patients in the unmatched (11.0% vs. 7.9%; p = 0.09) and matched (10.7% vs. 8.1%, p = 0.27) cohorts. Similarly, no differences in inguinodynia and recurrence were observed in either matched or unmatched cohorts. CONCLUSION Obese patients pose no further risk in outcomes compared to non-obese veterans undergoing open inguinal hernia repair. The best technique for an inguinal hernia repair in obese patients should rest on the comfort and the experience of the surgeon.
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Barbosa CDEA, Oliveira DC, DE-Melo-Delgado NM, Mafra JÚGDEA, Santos RSD, Moreira WC. Inguinodynia: review of predisposing factors and management. ACTA ACUST UNITED AC 2021; 47:e20202607. [PMID: 33439931 DOI: 10.1590/0100-6991e-20202607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/18/2020] [Indexed: 11/21/2022]
Abstract
Herniorrhaphy is one of the most common surgical procedures, with an estimated 20 million operations performed annually worldwide. One of the common complications associated with this procedure is inguinodynia, defined as pain beyond three months after inguinal hernia surgery. In this review, we have addressed the main aspects of this complication with current articles, published in the last five years. Inguinodynia has a multifactorial nature and studies have shown that its development is related to the surgical technique and intrinsic factors of the patient that imply greater predisposition to this phenomenon. In this regard, it has been discussed which surgical techniques imply a lower incidence of this complication. Many studies have focused on understanding intrinsic features of each patient, both in physical and cognitive aspects, and how the approach of these factors can favor a better post-surgical recovery. The treatment of this condition is still challenging, and there are no established universal guidelines. We believe that due to its multifactorial nature, the treatment is hampered due to the individuality inguinodynia presentations.
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Affiliation(s)
- CirÊnio DE Almeida Barbosa
- - Universidade Federal de Ouro Preto, Departamento de Cirurgia, Ginecologia e Obstetrícia e Propedêutica da Escola de Medicina - Ouro Preto - MG - Brasil.,- Colégio Brasileiro de Cirurgia, Titular - Belo Horizonte - MG - Brasil.,- Colégio Brasileiro de Cirurgia e do Aparelho Digestivo, Titular - Bela Vista - SP - Brasil
| | - Deborah Campos Oliveira
- - Universidade Federal de Ouro Preto, Departamento de Biotecnologia - Ouro Preto - MG - Brasil
| | - NathÁlia Moura DE-Melo-Delgado
- - Universidade Federal de Ouro Preto, Departamento de Cirurgia, Ginecologia e Obstetrícia e Propedêutica da Escola de Medicina - Ouro Preto - MG - Brasil
| | - JÚlia Gallo DE-Alvarenga Mafra
- - Universidade Federal de Ouro Preto, Departamento de Cirurgia, Ginecologia e Obstetrícia e Propedêutica da Escola de Medicina - Ouro Preto - MG - Brasil
| | - Ronald Soares Dos Santos
- - Universidade Federal de Ouro Preto, Departamento de Cirurgia, Ginecologia e Obstetrícia e Propedêutica da Escola de Medicina - Ouro Preto - MG - Brasil
| | - Weber Chaves Moreira
- - Colégio Brasileiro de Cirurgia, Titular - Belo Horizonte - MG - Brasil.,- Colégio Brasileiro de Cirurgia e do Aparelho Digestivo, Titular - Bela Vista - SP - Brasil
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Loss L, Meier J, Ordonez JE, Phung T, Balentine C, Zhu H, Huerta S. Feasibility of a Local Anesthesia Program for Inguinal Hernia Repair at a Veteran Affairs Hospital. J Surg Res 2020; 255:1-8. [DOI: 10.1016/j.jss.2020.05.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/14/2020] [Accepted: 05/03/2020] [Indexed: 02/06/2023]
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Tao Z, Renteria O, Huerta S. Pilonidal disease at a Veteran Affairs hospital. Am J Surg 2020; 220:1124-1125. [PMID: 32620216 DOI: 10.1016/j.amjsurg.2020.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Zoe Tao
- University of Texas Southwestern Medical Center, Department of Surgery and VA North Texas Health Care System, Dallas, TX, USA
| | - Oswaldo Renteria
- University of Texas Southwestern Medical Center, Department of Surgery and VA North Texas Health Care System, Dallas, TX, USA
| | - Sergio Huerta
- University of Texas Southwestern Medical Center, Department of Surgery and VA North Texas Health Care System, Dallas, TX, USA.
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Meier J, Huerta S. Primary Repair of Umbilical Hernias: Evidence of Feasibility. Am Surg 2020. [DOI: 10.1177/000313482008600421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jennie Meier
- Department of Surgery VA North Texas Health Care System Dallas, Texas
| | - Sergio Huerta
- Department of Surgery VA North Texas Health Care System Dallas, Texas
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Argo M, Favela J, Phung T, Huerta S. Local VS. other forms of anesthesia for open inguinal hernia repair: A meta-analysis of randomized controlled trials. Am J Surg 2019; 218:1008-1015. [DOI: 10.1016/j.amjsurg.2019.06.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/13/2019] [Accepted: 06/25/2019] [Indexed: 01/03/2023]
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Huerta S. Minimally invasive inguinal hernia repair is not superior to open. Hernia 2019; 24:217-218. [PMID: 31502074 DOI: 10.1007/s10029-019-02045-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/28/2019] [Indexed: 11/24/2022]
Affiliation(s)
- S Huerta
- Department of Surgery, VA North Texas Health Care System, University of Texas Southwestern, 4500 S. Lancaster Road, Dallas, TX, 75316, USA.
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Ochoa-Hernandez A, Timmerman C, Ortiz C, Huertas VL, Huerta S. Emergent groin hernia repair at a County Hospital in Guatemala: patient-related issues vs. health care system limitations. Hernia 2019; 24:625-632. [PMID: 31429024 DOI: 10.1007/s10029-019-02028-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 08/04/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The rate of emergent groin hernia repair in developing countries is poorly understood. MATERIALS AND METHODS A retrospective analysis of groin hernia repairs performed at a county hospital in Guatemala [Hospital Nacional de San Benito (HSNB)] was undertaken and compared to a literature review in developed countries. Patients with incarcerated hernias were interviewed to determine factors related to late presentation. RESULTS Twenty-five percent of patients with groin hernias in this analysis presented at HNSB emergently (vs. 2.5-7.7% in developed countries). Most patients were male in their fifth decade of life. Ten percent of hernias were femoral. There was no delay in scheduling patients for surgery presenting for elective repair. Most patients lived within 20 miles of the hospital, but only 50% of patients returned for their follow-up appointment. Most patients with an incarcerated inguinal hernia (56%) did not seek medical attention because of family obligations, but when they did, this decision was influence by their children (66%). None of the patients presenting with an incarcerated hernia had education past secondary school. In fact, most (56%) did not have any form formal education. Nearly 90% of patients who had an incarcerated hernia repaired thought that the hospital provided good-to-excellent care. CONCLUSION A high number of patients present emergently for groin hernia repair at a county hospital in Guatemala compared to developed countries. Our data suggest that emergent hernias are likely the result of patient-related issues rather than health care system limitations.
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Affiliation(s)
| | - C Timmerman
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - C Ortiz
- Hospital Nacional de San Benito, Petén, San Benito, Guatemala
| | - V L Huertas
- Hospital Nacional de San Benito, Petén, San Benito, Guatemala
| | - S Huerta
- University of Texas Southwestern Medical Center, Dallas, TX, USA. .,VA North Texas Health Care System, 4500 S. Lancaster Road, Dallas, TX, 75225, USA.
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Huerta S, Timmerman C, Argo M, Favela J, Pham T, Kukreja S, Yan J, Zhu H. Open, Laparoscopic, and Robotic Inguinal Hernia Repair: Outcomes and Predictors of Complications. J Surg Res 2019; 241:119-127. [PMID: 31022677 DOI: 10.1016/j.jss.2019.03.046] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 02/20/2019] [Accepted: 03/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The robotic approach to an inguinal hernia has not been compared head to head with the open and laparoscopic techniques in randomized controlled trials. Furthermore, long-term outcomes for robotic inguinal hernia repair (RHR) are lacking. In this study, we compared laparoscopic inguinal hernia repair (LHR) and RHR with open inguinal hernia repair (OHR) in veteran patients performed by surgeons most familiar with each approach. METHODS A retrospective single-institution analysis of 1299 inguinal hernia repairs performed at the VA North Texas Health Care System between 2005 and 2017 was undertaken. Three surgeons performed the operations, each an expert in one approach, and there was no crossover in techniques. A total of 1100 OHRs, 128 LHRs, and 71 RHRs were performed. Univariable analysis was undertaken to determine associations between techniques and outcomes (OHR versus LHR; OHR versus RHR; LHR versus RHR). Setting complications as a dependent variable, multivariable analyses were undertaken to determine an association with complications as well as independent predictors of complications. RESULTS Patient demographics were similar among groups except for age that was higher in the OHR cohort. The average follow-up was 5.2 ± 3.4 y. In the present report, recurrence was associated with a higher rate in the RHR versus OHR (5.6% versus 1.7%; P < 0.02), but not in the LHR versus OHR (3.9% versus 1.9%; P = 0.09). Inguinodynia was more likely to occur in both the LHR and RHR compared with the OHR (9.4% and 14.1 versus 1.5%; both P's < 0.001). Urinary retention was also more common in the LHR and RHR than in the OHR (5.5% and 5.6% versus 1.8%, both P's < 0.05) as was the rate of overall complications (34.4% and 38.0% versus 11.2%, both P's < 0.001). Multivariable regression analysis showed femoral hernias, ASA, serum albumin, operative room time, a recurrent hernia, and the minimally invasive approaches were independent predictors of overall complications. CONCLUSIONS Outcomes in the OHR cohort were, in general, superior compared with both the LHR and RHR. However, these strategies should be viewed as complementary. The best approach to an inguinal hernia repair rests on the specific expertise of the surgeon.
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Affiliation(s)
- Sergio Huerta
- Department of Surgery, University of Texas Southwestern, Medical Center, Dallas, Texas; Department of Surgery, VA North Texas Health Care System, Dallas, Texas.
| | - Corey Timmerman
- Department of Surgery, University of Texas Southwestern, Medical Center, Dallas, Texas
| | - Madison Argo
- Department of Surgery, University of Texas Southwestern, Medical Center, Dallas, Texas
| | - Juan Favela
- Department of Surgery, University of Texas Southwestern, Medical Center, Dallas, Texas
| | - Thai Pham
- Department of Surgery, University of Texas Southwestern, Medical Center, Dallas, Texas; Department of Surgery, VA North Texas Health Care System, Dallas, Texas
| | - Sachin Kukreja
- Department of Surgery, VA North Texas Health Care System, Dallas, Texas
| | - Jingsheng Yan
- Department of Surgery, University of Texas Southwestern Medical Center, Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Hong Zhu
- Department of Surgery, University of Texas Southwestern Medical Center, Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
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Ruiz M, Shahid Z, Renteria O, Huerta S. Current Trends in Training in the Surgical Management of Acute Appendicitis at a Veteran Affairs Hospital. JOURNAL OF SURGICAL EDUCATION 2019; 76:506-511. [PMID: 30249516 DOI: 10.1016/j.jsurg.2018.07.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/14/2018] [Accepted: 07/30/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION An open appendectomy used to be one of the most common cases performed by interns and physical exam dictated operative intervention. We hypothesized that the management of acute appendicitis has drastically changed from these previous practices. METHODS A retrospective, single institution study was performed at the VA North Texas Health Care System between July 2005 to June 2017 for all patients who underwent an appendectomy. Using postgraduate year (PGY)-level (PGY 1-3 and PGY 4-5) as a dependent variable, univariate analyses, and multiple logistic regression analyses were performed. All statistical tests were 2-sided, and the statistical significance level was set at a p ≤ 0.05. RESULTS Only patients with acute appendicitis were included (n = 257; male = 90.7%; age = 45.4 ± 15.6 year old; body mass index = 30.3 ± 6.3 Kg/m2). Of these, only 8 were performed by interns, 25 by PGY-2, 147 by PGY-3, 22 by PGY-4, and 55 by PGY-5. On presentation, 92.2% of patients had a computed tomography scan and 90.7% underwent a laparoscopic appendectomy. Conversion rate was 4.7%. There were 20 complications (7.8%) and length of hospital stay was 2.2±3.7 days. Comparing patients operated by senior (PGY-4 and 5) to junior (PGY-1 to -3) residents: patients were of similar age, gender, body mass index, American Society of Anesthesiologists (ASA), and had similar WBC and blood pressure on initial presentation (all p's > 0.05); but were more likely to have diabetes mellitus, hypertension or pulmonary disease. Complication rate was the same (7.8%) for both senior and junior residents. CONCLUSIONS At the VA North Texas Health Care System, most patients presenting with suspected appendicitis undergo a computed tomography scan. Most cases are performed laparoscopically mainly by PGY ≥ 3 residents. The rate of post-operative complications was similar between junior and senior residents.
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Affiliation(s)
- Maria Ruiz
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Zain Shahid
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Oswaldo Renteria
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sergio Huerta
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Surgery, VA North Texas Health Care System, Dallas, Texas.
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Surgical trends of groin hernia repairs performed for recurrence in medicare patients. Hernia 2018; 23:677-683. [PMID: 30414000 DOI: 10.1007/s10029-018-1852-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The recurrence rate after groin hernia repair (GHR) has been estimated to be between 1-10% in adult patients. Neither national rates nor trends in recurrence over time have been reliably established for Medicare patients in the USA. MATERIALS We evaluated patients undergoing GHR (inguinal = IHR; femoral = FHR) from 2011 to 2014 from the Medicare Provider Analysis and Review database. Patients were identified using ICD-9 diagnosis and ICD-9 and CPT procedure codes, stratified both by primary vs. recurrent hernia repair and by sex. One-tailed Cochran-Armitage tests evaluated trends over time and a generalized estimating equation model estimated factors associated with recurrent IHR or FHR. RESULTS We identified 407,717 patients (87.0%, ≥ 65 years) who underwent an IHR and 11,578 (91.0%, ≥ 65 years) who underwent a FHR. The proportion of IHRs for recurrence decreased statistically from 14.3% in 2011 to 13.9% in 2014 (p < 0.01) in males and was increased, but not statistically so (7.0-7.4%) in females (p = 0.08). The proportion of FHRs for recurrence was decreased, but not statistically so (16.3-14.8%, p = 0.29) in males and increased in females (5.3-6.3%, p = 0.02). On multivariable analysis, males were more than twice as likely as females to undergo recurrent repair (IHR or FHR, both p < 0.01). CONCLUSIONS Within the Medicare population, recurrence rates after groin hernia repairs were found to be higher than previously reported but have remained clinically stable over time. Establishing and reducing this rate is important for patient outcomes and expectations.
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Favela J, Huerta S. A case report of a groin pseudocyst following inguinal hernia repair and a review of the literature. Int J Surg Case Rep 2018; 50:32-35. [PMID: 30075359 PMCID: PMC6072967 DOI: 10.1016/j.ijscr.2018.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/11/2018] [Indexed: 11/14/2022] Open
Abstract
Groin pseudocyst is a rare complication following inguinal hernia repair. Only two previous cases reported in the literature. Pseudocysts can develop following open and laparoscopic mesh repair. Surgery is required for definitive management. In this report, we discuss a patient who had a groin pseudocyst 5 years after the original operation to repair his hernia.
Introduction Groin hernias are one of the most common general surgery operations performed worldwide and in the United States. We present an exceedingly unusual complication of a patient who underwent a posterior repair of an inguinal hernia. Presentation A 48-year-old man presented to our hospital with a chronically enlarging left groin mass for five years following a total extraperitoneal repair of a unilateral inguinal hernia. Two separate aspiration interventions led to rapid re-accumulation of the fluid. Physical exam demonstrated a large inguinoscrotal mass in the left groin. It was non-tender and there were no overlying skin changes. His testicles were palpable at the bottom of the scrotum. A computed tomography exam demonstrated evidence of a prior left inguinal hernia repair. The left groin/scrotum had a 12 cm fluid collection with incomplete peripheral calcification, consistent with previous history of seroma. An indirect hernial sac could not be excluded from the diagnosis. During groin exploration an inguinal canal pseudocyst was removed in its entirety without violating the capsule. The patient recovered well; there was no recurrence at a six month follow up. Review of the literature revealed that only two other cases had been reported, but in contrast to our case, the previous cases had an anterior repair for the index operation and the pseudocysts were open and partly resected. Conclusion Post-operative inguinal pseudocysts are exceedingly rare. Our case is the third reported in the literature. They can develop following open and laparoscopic mesh repair. Surgical intervention is required for definitive management.
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Affiliation(s)
- Juan Favela
- University of Texas Southwestern Medical Center and VA North Texas Health Care System, United States
| | - Sergio Huerta
- University of Texas Southwestern Medical Center and VA North Texas Health Care System, United States.
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Factors predicting chronic pain after open inguinal hernia repair: a regression analysis of randomized trial comparing three different meshes with three fixation methods (FinnMesh Study). Hernia 2018; 22:813-818. [PMID: 29728882 DOI: 10.1007/s10029-018-1772-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 04/21/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Chronic pain after inguinal hernioplasty is the foremost side-effect up to 10-30% of patients. Mesh fixation may influence on the incidence of chronic pain after open anterior mesh repairs. METHODS Some 625 patients who underwent open anterior mesh repairs were randomized to receive one of the three meshes and fixations: cyanoacrylate glue with low-weight polypropylene mesh (n = 216), non-absorbable sutures with partially absorbable mesh (n = 207) or self-gripping polyesther mesh (n = 202). Factors related to chronic pain (visual analogue scores; VAS ≥ 30, range 0-100) at 1 year postoperatively were analyzed using logistic regression method. A second analysis using telephone interview and patient records was performed 2 years after the index surgery. RESULTS At index operation, all patient characteristics were similar in the three study groups. After 1 year, chronic inguinal pain was found in 52 patients and after 2 years in only 16 patients with no difference between the study groups. During 2 years' follow-up, three (0.48%) patients with recurrences and five (0.8%) patients with chronic pain were re-operated. Multivariate regression analysis indicated that only new recurrent hernias and high pain scores at day 7 were predictive factors for longstanding groin pain (p = 0.001). Type of mesh or fixation, gender, pre-operative VAS, age, body mass index or duration of operation did not predict chronic pain. CONCLUSION Only the presence of recurrent hernia and early severe pain after index operation seemed to predict longstanding inguinal pain.
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Murphy BL, Ubl DS, Zhang J, Habermann EB, Farley DR, Paley K. Trends of inguinal hernia repairs performed for recurrence in the United States. Surgery 2018; 163:343-350. [DOI: 10.1016/j.surg.2017.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/16/2017] [Accepted: 08/02/2017] [Indexed: 01/08/2023]
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Taveras LR, Huerta S. A case report of a de Garengeot hernia in a nonagenarian veteran. Int J Surg Case Rep 2017; 41:301-303. [PMID: 29127919 PMCID: PMC5683743 DOI: 10.1016/j.ijscr.2017.10.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 10/29/2017] [Indexed: 12/04/2022] Open
Abstract
A hernia containing the vermiform appendix [de Garengeot hernia (DGH)] is an exceedingly rare event. Most cases of DGH are made during inguinal exploration. In the present report, we discuss a patient who underwent an operation which revealed a DGH with appendicitis. This case is unusual because it occurred in a nonagenarian male veteran patient. The unique aspect of this case is that it was performed in its entirety under local anesthetic.
Introduction A hernia containing the vermiform appendix [de Garengeot hernia (DGH)] is an exceedingly rare event. Appendicitis occurring in this setting if further unusual. Most cases of DGH are made during inguinal exploration. In the present report, we discuss a patient who underwent an operation which revealed a DGH with appendicitis. Presentation of a case A 94-year-old man with a past medical history significant for hypertension and Parkinson’s disease was admitted to the hospital for the management of an event of CHF exacerbation. He developed acute onset of a painful right inguinal bulge. He had no prior hernia history. On physical exam, he had a 3-cm, tender, non-reducible right inguinal bulge without skin changes. Laboratory analyses were normal without leukocytosis. An acute abdominal series was obtained and demonstrated no obstruction. A groin exploration was performed under local anesthetic. An abscess was found associated with a femoral hernia containing the vermiform appendix. An appendectomy was performed through the hernia sac. The hernia was repaired via a McVay technique. At thirty days after his procedure, he had no complications and no signs of recurrence. Conclusion Most cases of DGH are diagnosed intraoperatively. Limited work up might be sufficient for adequate management. Several surgical strategies are acceptable. Groin exploration, plus and minus an appendectomy, and tissue repair versus mesh placement are acceptable surgical strategies. Laparoscopic approach for the management of DGH has been reported.
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Affiliation(s)
- Luis R Taveras
- VA North Texas Health Care System, University of Texas Southwestern, Department of Surgery, Dallas, TX, United States
| | - Sergio Huerta
- VA North Texas Health Care System, University of Texas Southwestern, Department of Surgery, Dallas, TX, United States.
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Renteria O, Mokdad AA, Imran J, Huerta S. Resident postgraduate year does not influence rate of complications following inguinal herniorrhaphy. J Surg Res 2017; 219:61-65. [DOI: 10.1016/j.jss.2017.05.122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 04/25/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022]
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Comment to: Should we perform elective inguinal hernia repair in the elderly? Wu J. J. et al. Hernia 2017; 21:823-824. [PMID: 28429086 DOI: 10.1007/s10029-017-1612-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
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Weyhe D, Tabriz N, Sahlmann B, Uslar VN. Risk factors for perioperative complications in inguinal hernia repair - a systematic review. Innov Surg Sci 2017; 2:47-52. [PMID: 31579736 PMCID: PMC6754002 DOI: 10.1515/iss-2017-0008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 02/09/2017] [Indexed: 11/15/2022] Open
Abstract
The current literature suggests that perioperative complications occur in 8%–10% of all inguinal hernia repairs. However, the clinical relevance of these complications is currently unknown. In our review, based on 571,445 hernia repairs reported in 39 publications, we identified the following potential risk factors: patient age, ASA score, diabetes, smoking, mode of admission (emergency vs. elective surgery), surgery in low resource settings, type of anesthesia, and (in men) bilateral and sliding hernias. The most commonly reported complications are bleeding (0.9%), wound infection (0.5%), and pulmonary and cardiovascular complications (0.2%). In 3.9% of the included publications, a reliable grading of the reported complications according to Clavien-Dindo classification was possible. Using this classification retrospectively, we could show that, in patients with complications, these are clinically relevant for about 22% of these patients (Clavien-Dindo grade ≥IIIa). About 78% of all patients suffered from complications needing only minor (meaning mostly medical) intervention (Clavien-Dindo grade <III). Especially with regard to the low incidence of complications in inguinal hernia repair, future studies should use the Clavien-Dindo classification to achieve better comparability between studies, thus enabling better correlation with potential risk factors.
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Affiliation(s)
- Dirk Weyhe
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Georgstr. 12, 26121 Oldenburg, Germany
| | - Navid Tabriz
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Georgstr. 12, 26121 Oldenburg, Germany
| | - Bianca Sahlmann
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Georgstr. 12, 26121 Oldenburg, Germany
| | - Verena-Nicole Uslar
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Georgstr. 12, 26121 Oldenburg, Germany
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